2023-08659. Increasing Access to High-Quality Care and Supporting Caregivers

Executive Order 14095 of April 18, 2023

Increasing Access to High-Quality Care and Supporting Caregivers

By the authority vested in me as President by the Constitution and the laws of the United States of America, it is hereby ordered as follows:

Section 1 . Policy. High-quality early care and education and long-term care are critical to our Nation's economic growth and economic security. Early care and education give young children a strong start in life, while long-term care helps older Americans and people with disabilities live, work, and participate in their communities with dignity. Access to both types of care is also critical to our national security because it helps ensure the recruitment, readiness, and retention of our military service members.

Throughout this order, early care and education are collectively referred to as “child care.” References to “care” that do not specify the type of care refer to both child care and long-term care. References to the “care workforce” refer to individuals and businesses working in the fields of child care and long-term care.

A sizeable majority of families and individuals in the United States who require care cannot access the affordable, high-quality care they need. The markets for child care and long-term care for persons with disabilities and older adults who need support in their homes and communities fail to deliver enough high-quality care because of a persistent gap between the costs of providing this care and the prices families can pay. High-quality care is labor intensive and requires skilled workers, and providers have limited ability to reduce costs. As a result, even when high-quality care is available, it costs far more than many families and individuals can afford, causing them to forgo care altogether, seek lower-quality care options, juggle unconventional shifts at work, reduce their own paid work hours, drop out of the labor force, or make other arrangements. Care expenditures represent a significant and increasing share of families' budgets, with child care prices growing by approximately 26 percent and some types of long-term care costs growing by over 40 percent in the last decade. Inadequate supply is exacerbated by high turnover in the care workforce. Care workers—disproportionately women of color—are among the lowest-paid in the country and often have to rely on public benefits despite working complex and demanding jobs. Investments in the care workforce are foundational to helping to retain care workers and improving health and educational outcomes. In recent years, more than half of the long-term care workforce and nearly 20 percent of the child care workforce turned over each year. And the workforce remains 8 percent smaller than before the COVID–19 pandemic.

In 2019, more than three in four United States households that searched for care reported difficulty finding adequate care for their young children, and roughly the same share of center-based child care providers turned families away because they lacked enough child care slots. Similarly, more than three in four long-term care service providers have reported not being able to accept new clients, making it harder for older Americans and people with disabilities to find the care they need. Military families consistently cite access to high-quality child care as an impediment to military spouse employment and family economic security. Difficulty accessing care also poses a challenge for both spouses—and, as data shows, particularly for women in dual military couples—to continuing their service if they have caregiving responsibilities. The need for long-term care is likely to become more acute as our Nation's population ages. By 2060, there will be approximately twice as many adults over the age of 65 than in 2016, and projections indicate that there will be around 8 million long-term care job openings over the next decade.

Family caregivers provide informal, often unpaid, care to help loved ones live in their homes and communities, including caring for aging family members, people with disabilities, and children. At least 53 million people are family caregivers in the United States—including 5.5 million who are caring for wounded, ill, and injured service members and veterans—and many face challenges due to lack of support, training, and opportunities for rest. Family caregivers include spouses, parents, siblings, adult and minor children, grandparents, and other relatives. Family caregivers reflect the diversity of America's communities, and people can assume family caregiving responsibilities at any stage of life. Without adequate resources, family caregiving can affect caregivers' own physical and emotional health and well-being and contribute to financial strain. These negative consequences are felt most acutely by women, who make up nearly two-thirds of family caregivers and drop out of the workforce at a rate three times higher than men.

It is the policy of my Administration to enable families—including our military and veteran families—to have access to affordable, high-quality care and to have support and resources as caregivers themselves. It is also the policy of my Administration to ensure that the care workforce is supported, valued, and paid well. Additionally, care workers should have the free and fair choice to join a union.

The Congress must provide the transformative investments necessary to increase access to high-quality child care—including preschool and Head Start—and long-term care services, as well as high-quality, well-paying jobs that reflect the value the care workforce provides to families and communities. Such investments include removing barriers and providing the funding needed for Tribal Nations to effectively provide high-quality child care and long-term care.

Nearly every other advanced country makes greater public investments in care than the United States. Investing in care is an investment in the future of America's families, workforce, and economy.

While the Congress must make significant new investments to give families in this country more breathing room when it comes to care, executive departments and agencies (agencies) must do what they can within their existing authorities to boost the supply of high-quality early care and education and long-term care and to provide support for family caregivers. Through this order, I direct agencies to make all efforts to improve jobs and support for caregivers, increase access to affordable care for families, and provide more care options for families.

Sec. 2 . Increasing Compensation and Improving Job Quality for Family Caregivers, Early Educators, and Long-Term Care Workers. (a) To increase compensation and benefits for early childhood educators and long-term care professionals who are providing federally funded services:

(i) the Secretary of Health and Human Services, through the Administrator for the Centers for Medicare and Medicaid Services (CMS), shall issue guidance to States on ways to use enhanced funding to better connect home- and community-based workers who provide services to Medicaid beneficiaries;

(ii) the Secretary of Health and Human Services shall implement strategies to encourage comparability of compensation and benefits between staff employed by Head Start grant recipients and elementary school teachers;

(iii) the Secretary of Health and Human Services shall expand efforts to improve care workers' access to health insurance; and

(iv) the Secretary of Education shall use grant notices for the Child Care Access Means Parents in School (CCAMPIS) program to encourage grantees to improve quality in funded programs, including by increasing compensation and providing support services for early childhood educators who serve children of students at CCAMPIS colleges using Federal and non-Federal funding as appropriate;

(v) the Department of the Treasury shall conduct outreach on the Saver's Match credit, and the Department of Commerce shall conduct—and the Small Business Administration is encouraged to consider conducting—outreach on potential Federal resources available to assist small businesses in offering retirement plans, including a per-employee credit of up to $1,000, as provided in the SECURE 2.0 Act of 2022 (Division T of Public Law 117–328), in order to ensure that the care workforce, including individuals and small businesses, are aware of Federal retirement assistance for which they may be eligible.

(b) To improve working conditions and job quality in federally assisted child care and long-term care programs, encourage providers to establish incentives to recruit and retain workers, help prevent burnout, make it as easy as possible for care workers to access behavioral health services, and thereby improve the care that individuals receive, the Secretary of Health and Human Services shall:

(i) consider additional actions—such as providing guidance, technical assistance, and provider and resident education—and rulemaking on nursing home staffing transparency to promote adequate staffing at nursing homes, building on the Department of Health and Human Services' efforts to propose minimum standards for staffing adequacy at nursing homes;

(ii) consider additional actions to reduce nursing staff turnover in nursing facilities and improve retention of those staff, advancing the Department of Health and Human Services' efforts to measure and adjust payments based on staff turnover; and

(iii) implement strategies to expand mental health support for the care workforce, including early childhood providers supported through the Child Care and Development Fund (CCDF) and Head Start.

(c) To expand training pathways and professional learning opportunities to increase job quality, improve quality of care, and attract new entrants into the care workforce, the Secretary of Labor and the Secretary of Education, in consultation with the Secretary of Health and Human Services, shall:

(i) encourage recipients of Federal financial assistance to expand opportunities for early childhood educators and long-term care professionals through community college programming, career and technical education, Registered Apprenticeship, pre-apprenticeships leading to Registered Apprenticeship, and other job training and professional development;

(ii) make available innovative funding opportunities, develop and evaluate demonstration projects for care training and educational attainment, and provide technical assistance to State, local, and Tribal partners to improve job quality for care occupations; and

(iii) develop partnerships with key stakeholders, including State, local, Tribal, and territorial governments; unions and labor organizations; State and local workforce development boards; institutions of higher education (including community colleges, Historically Black Colleges and Universities, Tribal Colleges and Universities, and Minority Serving Institutions); aging and disability networks; and national- and community-based organizations that focus on care (including professional membership organizations).

(d) To support family caregivers of beneficiaries of Federal health care programs and services, and in conjunction with implementing the 2022 National Strategy to Support Family Caregivers:

(i) the Secretary of Health and Human Services shall, consistent with the criteria set out in section 1115A(b)(2) of the Social Security Act (42 U.S.C. 1315a(b)(2)), consider whether to select for testing by the Center for Medicare and Medicaid Innovation an innovative new health care payment and service delivery model focused on dementia care that would include family caregiver supports such as respite care;

(ii) the Secretary of Health and Human Services shall consider how better to evaluate and clearly set expectations for family caregivers in the Acute Hospital Care at Home program, which allows hospitals to treat in their homes those who would otherwise be hospital inpatients;

(iii) the Secretary of Health and Human Services shall take steps to ensure that hospitals are actively involving family caregivers in the discharge planning process, consistent with CMS condition of participation discharge planning requirements, including by promoting best practices such as partnerships with community-based organizations and using resources from the Administration for Community Living and the Agency for Healthcare Research and Quality;

(iv) the Secretary of Health and Human Services shall increase beneficiary communications and support family caregivers by increasing promotion of the option for Medicare beneficiaries to choose to give family caregivers access to their Medicare information via 1–800–MEDICARE and the State health insurance assistance program networks;

(v) the Secretary of Veterans Affairs shall consider issuing a notice of proposed rulemaking by the end of this fiscal year that would make any appropriate modifications to eligibility criteria for the Program of Comprehensive Assistance for Family Caregivers, which provides services and benefits, including a monthly stipend, for eligible caregivers of veterans who sustained a serious injury or illness in the line of duty; and

(vi) the Secretary of Veterans Affairs shall develop and implement a pilot program to offer psychotherapy via video telehealth to family caregivers within the Program of Comprehensive Assistance for Family Caregivers to improve their access to mental health services.

(e) To improve and expand opportunities through AmeriCorps to encourage more individuals to enter early learning careers, the Chief Executive Officer of AmeriCorps is encouraged to consider:

(i) expanding access to Segal AmeriCorps Education Awards, which AmeriCorps members can use to pay for education and training or reduce their student debt; providing loan forbearance for AmeriCorps members involved in early learning; and providing other benefits to supplement national service activities that support early learning; and

(ii) prioritizing applications that propose to implement or expand high-quality programs focused on early learning and prioritizing projects intended to prepare AmeriCorps members and AmeriCorps Seniors volunteers to enter early learning careers.

(f) To improve jobs of domestic child care and long-term care workers:

(i) the Secretary of Labor shall create and publish in multiple languages, as appropriate, compliance assistance and best practices materials—such as sample employment agreements for domestic child care and long-term care workers and their employers—to promote fair workplaces and ensure the parties know their rights and responsibilities, and shall identify other means to promote employers' adoption of best practices;

(ii) the Secretary of Labor shall work with community and other local partners to expand culturally and linguistically appropriate community outreach and education efforts to domestic child care and long-term care workers in order to combat their exploitation; and

(iii) the Chair of the Equal Employment Opportunity Commission is encouraged to work with the Attorney General, the Secretary of Labor, and the Secretary of Homeland Security to develop materials addressing the employment rights of non-citizen domestic child care and long-term care workers who are legally eligible to work.

(g) To improve data and information on the care workforce:

(i) the Secretary of Labor shall conduct and publish an analysis of early childhood and home care workers' pay in comparison to the pay of other workers with similar levels of training and skill;

(ii) the Secretary of Labor shall issue guidance to help States and localities conduct their own analyses of comparable pay rates for care workers in their respective jurisdictions; and

(iii) the Secretary of Labor and the Secretary of Health and Human Services shall, in consultation with relevant agencies and external experts and organizations, jointly conduct a review to identify gaps in knowledge about the home- and community-based workforce serving people with disabilities and older adults; identify and evaluate existing data sources; and identify opportunities to expand analyses, supplement data, or launch new efforts to provide important data on the home- and community-based care workforce and ensure equity for people with disabilities and older adults. The Secretaries shall publicly release the findings and recommendations of this review no later than April 2024.

Sec. 3 . Making Care More Accessible and Affordable for Families. (a) To increase access to affordable, high-quality child care and long-term care for workers delivering federally assisted projects:

(i) Agencies shall identify and issue guidance on which agency discretionary, formula, and program-specific funds can be used for child care and long-term care as a supportive service for workers who are being trained for and working on federally funded projects, and in doing so shall consider agency funds made available by the bipartisan Infrastructure Investment and Jobs Act (Public Law 117–58); Public Law 117–169, commonly referred to as the Inflation Reduction Act of 2022; and division A of Public Law 117–167, known as the Creating Helpful Incentives to Produce Semiconductors (CHIPS) Act of 2022.

(ii) With respect to the agency funds identified in subsection (a)(i) of this section:

(A) Agencies shall consider requiring, where appropriate, applicants for Federal job-creation or workforce development funds to provide affordable, accessible, safe, and reliable child care and long-term care for workers carrying out federally assisted projects (including both construction and operating phases where applicable), or shall consider preferencing applicants that use the funds for this purpose or encouraging applicants to use funds for this purpose. Agencies shall provide implementation guidance to relevant program staff and collaborate with the Department of Labor to identify potential support for these actions, including technical assistance for guidance and funding opportunities.

(B) Agencies shall consider providing technical assistance to help funding recipients provide access to child care and long-term care as a supportive service and to connect funding recipients with potential partners, including care associations, community-based organizations, Registered Apprenticeship and pre-apprenticeship programs, and labor unions.

(C) In cases where child care or long-term care is required or encouraged, agencies shall consider collecting information from funding recipients on whether and how they will provide access to child care and long-term care, and how many workers (including apprentices and pre-apprentices) would be affected.

(iii) The Secretary of Labor and the Secretary of Health and Human Services, in consultation with the Secretary of Commerce, shall support the efforts outlined in subsection (a) of this section by issuing guidance and providing technical assistance with best practices and models for how to provide supportive services, including child care and long-term care.

(b) To lower child care costs for families eligible for Federal programs, the Secretary of Health and Human Services shall:

(i) consider issuing regulations to pursue policies to reduce child care costs for families benefiting from CCDF;

(ii) identify potential opportunities to reduce barriers to eligibility for Head Start and CCDF;

(iii) encourage States, through all available avenues, to increase the use of Temporary Assistance for Needy Families funds for basic assistance and work supports for families—including access to child care—and to spend more funds on cash assistance for families; and

(iv) identify other potential strategies to make child care and Head Start more accessible for those families most in need.

(c) To help more Federal employees access affordable care:

(i) the Director of the Office of Personnel Management shall consider establishing criteria that support equitable and accessible employee participation in child care programs, to include agencies' adoption of income thresholds that are aligned with increasing costs of child care;

(ii) the Director of the Office of Personnel Management shall conduct a review of child care subsidy policy and agency program data to determine the effectiveness of current child care subsidies within the Federal Government;

(iii) the heads of agencies are encouraged to expand employee access to child care services through Federal child care centers, child care subsidies, or contracted care providers; and

(iv) the Department of Defense shall take steps to enhance recruitment and retention of the Department's child development program workers and to improve the affordability of child care for service members by September 2023, in addition to its ongoing efforts as part of the Fourteenth Quadrennial Review of Military Compensation to assess how child care costs impact the ability of the military to attract and retain its workforce.

Sec. 4 . Expanding Options for Families by Building the Supply of Care. (a) To provide families with more options for high-quality long-term, home-, and community-based care and early learning services:

(i) The Secretary of Health and Human Services shall consider rulemaking to improve access to home- and community-based services under Medicaid. As part of any such rulemaking, the Secretary shall consider taking steps to support provider participation in Medicaid home- and community-based programs.

(ii) The Secretary of Health and Human Services shall issue policies that would support child care providers to give families more options to access high-quality child care providers, and shall update payment practices to improve provider stability and supply.

(iii) The Secretary of Education shall update a guide for schools and districts to expand high-quality early learning programming using Federal funds so that more preschoolers are fully prepared to succeed in school.

(iv) The Secretary of Education and the Secretary of Health and Human Services shall identify and disseminate evidence-based practices for serving children with disabilities and their families in high-quality early childhood education programs, including Head Start. The Secretaries shall also take steps to ensure that services are inclusive of children with disabilities and their families; highlight any resources that are available to aid in that effort, including for preschool-aged children with disabilities under section 619 of the Individuals with Disabilities Education Act (IDEA) and for infants and toddlers with disabilities and their families under Part C of the IDEA; and provide information to support all early childhood programs in meeting their obligations under section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990.

(v) The Director of the Bureau of Consumer Financial Protection is encouraged to consider developing financial guidance resources that support families during their care planning.

(vi) The Secretary of Health and Human Services shall take steps to streamline processes for Tribes to use CCDF and Head Start funding to construct and improve facilities, including facilities that are jointly funded.

(vii) The 12 agencies that signed the October 2022 Memorandum of Agreement to implement Public Law 102–477 (the “Tribal 477 Program”) shall increase the effectiveness of Tribal employment and training programs to ensure child care can be used as a support for families by reducing and streamlining administrative requirements, including through consolidation of budgeting, reporting, and auditing systems.

(b) To expand options for quality home- and community-based services to veterans:

(i) The Secretary of Veterans Affairs shall consider expanding the existing Veteran Directed Care Program—which provides veterans who need help with daily living with a budget to spend on home- and community-based services including personal care services—to all Department of Veterans Affairs Medical Centers by the end of Fiscal Year 2024, and shall consider developing an implementation plan for this expansion by June 2023.

(ii) The Secretary of Veterans Affairs shall consider designing and evaluating a pilot program in no fewer than five veteran sites or in five States for a new Co-Employer Option for delivering veteran home health services. Features of the program may include allowing veterans to choose who provides their care and to determine when and how that care is delivered, and connecting veterans with a third-party agency that would help coordinate administrative tasks and act as an intermediary between veterans and their home health workers. Should the Department of Veterans Affairs implement this pilot program, it shall provide an implementation plan—including cost estimates and evaluation strategy—to the President, through the Assistant to the President for Domestic Policy, before August 31, 2023.

(iii) The Secretary of Veterans Affairs shall consider expanding the Home-Based Primary Care program by adding 75 new interdisciplinary teams to provide care to veterans in their homes.

(c) To increase the supply of providers and options for families by encouraging greater private financial protection, support, and technical assistance for care providers:

(i) the Secretary of the Treasury shall consider providing information to and sharing industry best practices with Community Development Financial Institutions to facilitate capital flows and support to care providers;

(ii) the Administrator of the Small Business Administration is encouraged to consider publishing a guide on how individuals in the care workforce may start and sustainably operate care businesses locally and through Small Business Administration programming; and

(iii) the Director of the Bureau of Consumer Financial Protection is encouraged to consider issuing guidance addressing financial institution practices that may increase the burden on the care workforce, discourage their work, and harm their financial well-being.

(d) To build the capacity of local communities to better coordinate and deliver care:

(i) the Secretary of Health and Human Services shall review existing policies to identify opportunities—including among Tribal communities—to increase the capacity of community care entities by providing operational support to these networks of providers; and

(ii) the Secretary of Agriculture shall use the Rural Partners Network and issue guidance developed in partnership with the Secretary of Health and Human Services to promote opportunities—including by hosting workshops—to increase access to child care and long-term care in rural and Tribal communities.

(e) To make the delivery and design of Federal care assistance and programs work better for families, the care workforce, and people seeking care, the Secretaries of the Treasury, Defense, Agriculture, Labor, Health and Human Services, Education, and Veterans Affairs shall consider—and the Administrator of the Small Business Administration is encouraged to consider—prioritizing engagement with parents, guardians, and other relatives with care responsibilities; individuals receiving long-term care; State and local care experts; care providers and workers; employers; and labor unions.

Sec. 5 . General Provisions. (a) Nothing in this order shall be construed to impair or otherwise affect:

(i) the authority granted by law to an executive department or agency, or the head thereof; or

(ii) the functions of the Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals.

(b) This order shall be implemented consistent with applicable law and subject to the availability of appropriations.

(c) Where not already specified, independent agencies are encouraged to comply with the requirements of this order.

(d) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.

  THE WHITE HOUSE, April 18, 2023. Filed 4–20–23; 11:15 am]